MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

March 2012

CONTENTS
Foreword Introduction Incidence and Definitions Management of Severe Pre-Eclampsia Management of Eclampsia References Recommended Reading Appendices Appendix 1 Magnesium Sulphate Regimen and Monitoring Appendix 2 Algorithm for the Management of Imminent Eclampsia and Eclampsia Appendix 3 Abbreviations Appendix 4 Emergency Box for Eclampsia Appendix 5 Patient Information 18 21 3 4 5 6 13 15 16

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Appendix 6 Membership of the Pre-eclampsia and Eclampsia Working Group 25

All statements in italics are direct quotes from the stated references.

FOREWORD
Guidelines for the Management of Severe Pre-Eclampsia and Eclampsia. These guidelines have been published by the Guidelines & Audit Implementation Network (GAIN), which is a team of health care professionals established under the auspices of the Department of Health, Social Services & Public Safety in 2010. The aim of GAIN is to promote quality in the Health Service in Northern Ireland, through audit and guidelines, while ensuring the highest possible standard of clinical practice is maintained. This guideline is a review of the Clinical Resource Efficiency Support Team (CREST) August 2001 guideline and was produced by a sub-group of health care professionals from varied backgrounds and was chaired by Dr H Sidhu, Consultant Obstetrician and Gynaecologist. GAIN wishes to thank all those who contributed in any way to the development of these guidelines.

INTRODUCTION
Obstetric emergency guidelines are drawn up to improve the consistency of management of pregnant women and their unborn children. As different teams of doctors and midwives are involved in the management of emergencies, standardisation should improve the efficiency of the unit and the outcomes for mother and child. Guidelines are not intended to replace the process of critical evaluation of every case and individualised decision making. Consultant staff should always be involved in the decisions taken in the management of all obstetric emergencies but until such time as they are informed and available, these guidelines will help midwives and junior staff to initiate immediate management. An early combined obstetric and anaesthetic approach to monitoring and management provides optimal care. Women with pre-eclampsia, in common with others who have poorly understood diseases, have suffered from many treatments that ultimately turned out to be ineffective or even harmful, but which were difficult to question when they were in common use. ...Hardly any mothers or babies die directly from a first convulsion in hospital; they die, if at all, from the underlying disease.
1

These guidelines have been collated from what is currently practised in Labour Wards in Northern Ireland, using RCOG guidelines and evidence-based information where possible. Review Date: 2014 Dr H Sidhu Consultant in Obstetrics & Gynaecology

Incidence
Severe pre-eclampsia and eclampsia are relatively uncommon but can cause serious complications of pregnancy. In the triennium 2006-2008 there were 19 maternal deaths resulting from severe pre-eclampsia and eclampsia.2 Severe pre-eclampsia and eclampsia were the second leading cause of Direct Maternal deaths. It is estimated that around 5/1000 maternities in the UK suffer from severe preeclampsia3 and 5/10,000 maternities develop eclampsia.4

Definitions
Eclampsia is defined as a convulsive condition associated with pre-eclampsia
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Severe pre-eclampsia is defined as pre-eclampsia with severe hypertension with diastolic blood pressure 110 mmHg, systolic blood pressure 160 mmHg and/or with symptoms, and/or biochemical and/or haematological impairment The clinical features of severe pre-eclampsia (in addition to hypertension and proteinuria) are: severe headache sudden swelling of face, hands, feet visual disturbance such as blurring or flashing before eyes epigastric pain and/or vomiting signs of clonus papilloedema liver tenderness platelet count falling to below 100 x 106/l HELLP syndrome
6 5

abnormal liver enzymes (ALT or AST rising to above 70iu/l)

MANAGEMENT OF SEVERE PRE-ECLAMPSIA

1. Principles of Management Assess Observe/monitor Investigate Control blood pressure Prevention of seizures Steroids for fetal lung maturity Careful fluid balance Consider the need for in utero/neonatal transfer Timing of Delivery Continue vigilance post delivery Follow up 2. Admit for assessment if: Systolic blood pressure 160 mmHg, or if Diastolic blood pressure 100 mmHg, or if Hypertension and proteinuria +, or if Presence of any clinical signs or symptoms 3. Inform of admission: Obstetric Registrar and Consultant Paediatric Registrar and Consultant Anaesthetic Registrar and Consultant 4. Observe and monitor Blood pressure measurement : every 15 minutes until stable, then every 30 minutes. Less frequent monitoring may become appropriate in some situations following full assessment Generalised oedema Symptoms Optic fundi Reflexes +/- clonus 6

 Test all urine specimens for protein Measure and record all fluid intake and urinary output MEOWS chart Fetal cardiotocograph (continuous if in labour) Fetal ultrasound scan for EFW, AFV, placental maturity, Fetal Umbilical Artery Doppler studies Middle Cerebral Artery Doppler studies if fetal umbilical artery doppler studies are abnormal or there is other concern about fetus e.g. IUGR or reduced fetal activity 5. Investigations Blood Full blood picture including Platelets Urea & Electolytes Urate Serum Creatinine investigations (uric acid) Liver Function Tests Coagulation screen if platelet count less than100 x 106/l Group and hold serum Urine 24-hour urine collections for: i. Total protein and creatinine clearance ii. Catecholamines 6. Control of Blood Pressure Cerebral haemorrhage is the main cause of death in women with preeclampsia/ eclampsia. To prevent haemorrhagic stroke, severe life-threatening hypertension, especially high systolic blood pressure, must be treated quickly and effectively.
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Treat hypertension if: Systolic blood pressure 160 mmHg, or if Diastolic blood pressure 110 mmHg, or if

Mean arterial pressure 125 mmHg, or if Blood pressure 160/110 mmHg but other evidence of severe disease Aim to reduce blood pressure to around 130-140/90-100 mmHg A rapid and precipitous fall in maternal blood pressure or maternal hypotension as a result of intravenous anti-hypertensive drugs, especially hydralazine, may cause fetal heart rate abnormalities, especially in growth restricted/compromised fetuses. Monitor fetal heart with continuous CTG during and for 30 minutes after administration of intravenous anti-hypertensive drugs Aim to stabilise blood pressure before delivery. Anti-hypertensive drugs The choice of antihypertensive in severe pre-eclampsia has evolved historically rather than scientifically. Effective and safe control of severe hypertension is the most important aspect of critical care management, as the main cause of maternal death is the consequence of poorly controlled hypertension.5 The choice of antihypertensive drugs for acute control varies but is usually labetalol, hydralazine or nifedipine.7 Drugs: Labetalol orally or intravenously (Labetalol should be avoided in women with known asthma) - 200mg orally stat if possible, repeated hourly for up to 4 hours or - Up to 50 mg IV stat slowly; then if necessary erect IV infusion of 200 mg in 200 ml NaCl 0.9%, starting at 40 mg/hour, doubling dose at half hourly intervals as required to a maximum of 160 mg/hour. Nifedipine - Decision to administer nifedipine antenatally should be made by consultant staff 8

- Oral route is safer and as effective as sublingual route - 10 mg oral stat dose - Repeat every 20 minutes to a maximum of 40 mg - Monitor fetal heart with CTG NOTE: An interaction between nifedipine and magnesium sulphate has been reported to produce profound muscle weakness, maternal hypotension and fetal distress.8, 9, 10, 11 Hydralazine: - 10 mg IV slowly - a further bolus of 5 mg IV after a 20 minute interval may be given if necessary (the effect of a single dose can last up to 6 hours) - If no lasting effect with boluses of hydralazine (assess over 20 minutes), consider an infusion of 2.0 mg/hour increasing by 0.5 mg/hour as required (2-20 mg/hour usually required) - Close liaison with anaesthetists: may require plasma expansion5 Consider using up to 500 ml crystalloid fluid before or at the same time as the first dose of intravenous hydrallazine in the antenatal period. In women with severe hypertension who are in critical care, aim to keep systolic blood pressure below 150 mmHg and diastolic blood pressure between 80 and 100 mmHg
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In women with less severe disease not requiring urgent delivery (blood pressure < 160/110 mmHg), maternal antihypertensive treatment with methyldopa or labetalol may allow prolongation of pregnancy for up to 15 days, although there may be a small reduction in birth weight12 7. Prevention of seizures Magnesium sulphate is the drug of choice13 and should be considered if there is concern about the risk of eclampsia7 (Appendix 1)

Assess patients for the presence of: severe headache with visual disturbance, hyper-reflexia, clonus, irritability, restlessness If magnesium sulphate is given, it should be continued for 24 hours after delivery or 24 hours after the last seizure, whichever is the later, unless there is a clinical reason to continue7 If magnesium sulphate is given antenatally, monitor the fetal heart with continuous CTG. 8. Corticosteroids Initiate corticosteroids if gestation < 34 weeks. Every effort should be made to initiate antenatal corticosteroid therapy in women between 24 and 34 weeks gestation. Between 35 to 36 weeks gestation obstetricians may wish to consider antenatal steroid use. Recommended therapy involves two doses of betamethasone 12mg, given intramuscularly 24 hours apart.14 9. Principles of Fluid Balance FLUID RESTRICTION IS ADVISABLE TO REDUCE THE RISK OF FLUID OVERLOAD IN THE INTRAPARTUM AND POSTPARTUM PERIODS BEWARE: Over the last 20 years pulmonary oedema has been a significant cause of maternal death in Severe Pre-Eclampsia/Eclampsia. This has often been associated with inappropriate fluid management.15 1. Accurate Recording of Fluid Balance - including delivery and postpartum blood loss, input/output deficit 2. Maintenance Crystalloid Infusion - 80 ml/hour, or 1 ml/kg/hour7

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3. Selective Colloid Expansion may be necessary prior to pharmacological vasodilatation to prevent maternal hypotension and fetal compromise or in oliguria with low CVP: Colloid should only be given after discussion with anaesthetist 4. Diuretics: only for women with confirmed pulmonary oedema 5. Avoid non-steroidal analgesia until fluid recovery 10. Consider the need for in utero/neonatal transfer:7 If a Maternity Unit does not have access to HDU/ICU or is unable to cope with maternal complications, or is unable to cope with pre-term babies, it may be appropriate to consider antenatal transfer of the mother. However, maternal safety must not be jeopardised and each case should be considered on its clinical merits; in most cases it is safer to deliver the mother and then consider the need for transfer of mother and/or child. Maternity Units should consider developing transfer protocols to ensure that patients are transferred with appropriate personnel and equipment. Transfer documentation needs to be standardised. 11. Birth A team effort involving obstetricians, midwives, anaesthetists and paediatricians The timing of birth is dependent on the maternal and fetal condition. Either caesarean section or induction of labour may be appropriate depending on the clinical findings.5 In eclampsia, the definitive treatment is delivery However, it is inappropriate to deliver an unstable mother even if there is fetal compromise. Once seizures are controlled, severe hypertension treated and hypoxia corrected, delivery can be expedited. 11

The third stage should be managed with 5 units of Syntocinon, either intramuscularly or slowly intravenously. Ergometrine should not be used in severe pre-eclampsia and eclampsia. Consider Prophylaxis against Thromboembolism.16 12. Principles of Care After Birth Maintain vigilance as the majority of eclamptic seizures occur after delivery High dependency care should be provided as clinically indicated (24 hours minimum)
7, 17

Consider the need for admission to ICU. Close monitoring should be undertaken by experienced staff: nurse/midwife should be allocated to provide one to one care, with input from senior medical staff Maintain close attention to fluid balance Monitor platelets, transaminases and creatinine until they have returned to normal values Review anti-hypertensive medication as indicated: methyldopa should be avoided postpartum because of its tendency to cause depression. -Blockers (e.g. atenelol 50-100 mg daily), with the addition of a calcium antagonist (e.g. slow-release nifedipine 10-20 mg b.d.) and/or an ACE inhibitor (e.g. enalapril 5-10 mg b.d.) if required, are appropriate for the treatment of postpartum hypertension. Review Magnesium sulphate medication as indicated

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13. Follow-Up If eclampsia has occurred, consider CT scan of the head Specific investigations: anti-phospholipid antibodies, lupus anticoagulant and thrombophilia screen.18 Discussion with mother concerning what has happened and its significance for the future Inform general practitioner and community midwives at discharge. Arrange long-term follow-up to make sure that blood pressure resolves. Arrange hospital review 2 weeks after discharge if discharged home on antihypertensive medication5 In women who have had severe pre-eclampsia and/or eclampsia, arrange hospital review at 6 weeks to check bloods, proteinuria (refer for specialist kidney assessment if still present), monitor BP (refer to physicians if still elevated); and for final debriefing 5 Offer future preconceptual counselling to consider risk factors and preventative therapy (e.g. aspirin, lose weight)

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MANAGEMENT OF ECLAMPSIA19
DO NOT LEAVE PATIENT ALONE ACTIVATE EMERGENCY BUZZER & CALL FOR HELP Duty obstetric & anaesthetic registrars; senior midwife; INFORM duty consultant obstetrician & anaesthetist Arrange for ECLAMPSIA BOX to be brought in Is it safe to approach the patient? Consider hazards around patient that will affect your safety Prevent maternal injury during convulsion Place patient in semi-prone position (left side) Airway Assess Protect airway and maintain patency Give high-flow oxygen Breathing Assess Ventilate as required Circulation Evaluate pulse & blood pressure If absent, initiate CPR: 30 chest compressions / 2 rescue breaths. Call ARREST TEAM Left lateral tilt / displace uterus with wedge Secure IV access as soon as safely possible Fluids by infusion pump at no more than 1mg/kg/hr

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Medication for the Management of Seizures The vast majority of the initial seizures are self-limiting20 MAGNESIUM SULPHATE is the anticonvulsant drug of choice13 4g iv bolus: See APPENDIX 1 for regimen Avoid polypharmacy to treat seizures increases risk of respiratory arrest Observations & Investigations As per Management of Severe Pre-Eclampsia Take Blood Gases and baseline bloods Respirations and oxygen saturation - attach pulse oximeter Attach ECG and automatic blood pressure monitors Urinary catheter hourly urinometer readings and test for protein Fluid input/output chart MEWS chart Check for aspiration - always auscultate lungs after the convulsion has ended Continuous electronic fetal monitoring Deliver once stabilised if antenatal DOCUMENTATION Timings Drugs administered Persons present

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REFERENCES
1. 2. Thornton JG. Prophylactic anticonvulsants for pre-eclampsia. Br J Obstet Gynaecol 2000; 107: 839-840 Lewis G, editor: Saving Mothers Lives. Reviewing maternal deaths to make motherhood safe: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. B J Obstet Gynaecol 2011: 118, Supplement 1 3. Tuffnell DJ, Jankowicz D, Lindow SW, Lyons G, Mason GC, Russell IF, Walker JJ. Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003. BJOG 2005; 112:875-80 4. 5. 6. Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ 1994; 309: 1395-400 NICE Clinical Guideline: Hypertension in pregnancy: the management of hypertensive disorders during pregnancy. August 2010 Sharma SK, Philip J, Whitten CW, Padakandla UB, Landers DE. Assessment of changes in coagulation in parturients with pre-eclampsia using thromboelastography. Anesthesiology 1999; 90: 395-90 7. 8 The Management of Severe Pre-eclampsia/Eclampsia. RCOG Guideline No. 10(A). March 2006 Reviewed 2010 Impey L. Severe hypotension and fetal distress following sublingual administration of nifedipine to a patient with severe pregnancy-induced hypertension at 33 weeks. BJOG 1993; 100: 959-961. 9. Waisman GD, Mayorga LM, Camera MI, Vignolo CA, Martinotti A. Magnesium plus nifedipine: Potentiation of hypotensive effect in pre-eclampsia. AM J Obstet Gynecol 1988; 159: 308-309 10. Ben-Ami M, Giladi Y, Shaley E. The combination of magnesium sulphate and nifedipine: a cause of neuromuscular blockade. Br J Obstet Gynaecol 1994; 101: 262-263 11. Scott W, Snyder MD, Cardwell MS. Neuromuscular blockade with magnesium sulfate and nifedipine. Am J Obstet Gynecol 1989; 161: 35-36 12. Magee LA, Ornstein MP, von Dadelszen P. Fortnightly review: management of hypertension in pregnancy. BMJ 1999; 318: 1332-6

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13. Lubarsky SL, Barton JR, Friedman SA, Nasreddine S, Ramadan MK, Sibai BM. Late postpartum eclampsia revisited. Obstet Gynaecol 1994; 83: 502-5 14. Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality. RCOG Green-top Guideline No. 7. October 2010 15. Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Inquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004 16. Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium. RCOG Green-top Guideline No. 37a. November 2009 17. Review of Adult Intensive Care Services in Northern Ireland. CREST 1998 18. Hunt BJ, Scully M, Nelson-Piercy C, Bewley S & Khamashta. Antiphospholipid antibodies and pregnancy. Reprod Vasc Med 2000; 1: 8-13 19. Sidhu H. Pre-eclampsia and Eclampsia. In Johanson R, Cox C, Grady K, Howell C, editors. Managing Obstetric Emergencies and Trauma: The MOET Course Manual. London: RCOG Press; 2003: 133-47 20. Sibai BM. (1996) Hypertension in Gabbe SG, Simpson Jl, (Eds.) Obstetrics: normal and problem pregnancies. Third Edition Chapter 28, pp 969-971. Churchill Livingstone: New York

RECOMMENDED READING
Nelson-Piercy C. In Handbook of Obstetric Management, Hypertension and Severe Pre-eclampsia. Fourth Edition 2010

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APPENDICES

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APPENDIX 1
MAGNESIUM SULPHATE REGIMEN AND MONITORING
Administer via infusion pump Loading Dose 4 g IV over 10-15 minutes Add 8 ml of 50% MgSO4 to 12 ml N Saline = 4 g in 20 ml = 20% solution Maintenance 1 g per hour Add 25 g MgSO4 (50 ml) to 250 ml N Saline 1 g MgSO4 = 12 ml per hour IV 1 g/hour is infused for 24 hours after delivery or after last seizure, whichever is later, provided that: Respiratory rate > 16 breaths/minute Urine output > 25 ml/hour, and Patellar reflexes are present REMEMBER TO SUBSTRACT VOLUME INFUSED FROM TOTAL MAINTENANCE INFUSION VOLUME (80 ml/hour) A higher maintenance dose may be required initially to prevent recurrent seizures consultant must make this decision If seizure continues, or if seizures recur, give a second bolus of magnesium sulphate: 2-4 g depending on weight of patient, over 5-10 minutes (2 g if < 70 kg and 4 g if > 70 kg) ONE STAT DOSE ONLY

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Alternately, increase the rate of magnesium sulphate infusion to 1.5g or 2.0g/hour If seizures persist, then alternate agents such as diazepam or thiopentone may be used, but only as single doses, since prolonged use of diazepam is associated with an increase in maternal death. Intubation may become necessary in such women to protect the airway and ensure adequate oxygenation. Transfer to intensive care facilities with intermittent positive pressure ventilation is appropriate in these circumstances

When using Magnesium Sulphate

Monitor Hourly urine output Respiratory rate, oxygen saturation and patellar reflexes every 10 minutes for first two hours and then every 30 minutes Check serum magnesium levels every day if infusion is continued for >24 hours Request MgSO4 Levels if Respiratory rate < 16 breaths/minute (CARE: lower rate may be appropriate if on opiates) Urine output < 25 ml/hour for 4 hours Loss of patellar reflexes Further seizures occur Magnesium Levels With increasing magnesium levels, the following may occur: Feeling of warmth, flushing, double vision Slurred speech. . . . . . . . . . . . . . . . . . 3.8-5.0 mmol/l Loss of tendon reflexes . . . . . . . . . . . . >5.0 Respiratory Depression . . . . . . . . . . . >6.0 Cardiac Arrest. . . . . . . . . . . . . . . . . . >12.0 mmol/l mmol/l mmol/l 21 Therapeutic 2.0 4.0 mmol/l

Respiratory Arrest . . . . . . . . . . . . . . . 6.3-7.1 mmol/l

Magnesium Toxicity

Urine output <100 ml in 4 hours: If no clinical signs of magnesium toxicity, decrease rate to 0.5 g/hour Review overall management with attention to fluid balance and blood loss Absent patellar reflexes: Stop MgSO4 infusion until reflexes return Respiratory Depressions: Stop MgSO4 infusion Give oxygen via facemask and place in recovery position because of impaired level of consciousness Monitor closely Respiratory Arrest: Stop MgSO4 infusion Give IV Calcium Gluconate Intubate and ventilate immediately Cardiac Arrest: Commence CPR Stop MgSO4 infusion Give IV Calcium Gluconate Intubate and ventilate immediately If antenatal, immediate delivery

Antidote

10% Calcium Gluconate 10 ml IV over 10 minutes

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APPENDIX 2
Management of IMMINENT ECLAMPSIA or ECLAMPSIA
DO NOT LEAVE PATIENT ALONE Place in semi-prone position Call for HELP Duty obstetric & anaesthetic registrars; senior midwife Inform consultants obstetrician and anaesthetist on-call OBSERVATIONS Pulse Oximeter BP Respirations Temperature ECG Test urine for protein Hourly urine output Fluid balance / MEOWS chart FH monitor continuously INVESTIGATIONS FBP & Platelets U&E Urate Serum Creatinine LFTs Coagulation Screen Group and Hold Serum MSSU/CSU 24 hr urine collections for: Total protein & creatinine clearance Catecholamines

AIRWAY

Assess; consider left lateral tilt Protect Airway and maintain patency Give oxygen Assess Ventilate as required Evaluate pulse & BP If absent, start CPR: 30 compressions/2 breaths Call ARREST TEAM Secure IV access as soon as safely possible Loading dose MgSO4: Maintenance dose MgSO4:

BREATHING

CIRCULATION

CONTROL SEIZURES

4 mg MgSO4 in 20% solution IV over 10-15 minutes Add 8ml of 50% MgSO4 solution to 12 ml N Saline 1g per hour infusion Add 25g MgSO4 (50 ml) to 250 ml N Saline 1g MgSO4 = 12 ml per hour IV MgSO4 2g 70kg; 4g 70kg IV as per loading dose over 5-10 minutes. Hourly urine output Respiratory rate, O2 saturation & patellar reflexes every 10 minutes for first 2 hours and then every 30 minutes Check serum magnesium levels daily if infusion is continued for >24 hours Check magnesium levels and review management with consultant if: Urine output < 100ml in 4 hours Patellar reflexes are absent Respiratory rate < 16 breaths/minute Oxygen saturation <90% 10% Calcium gluconate 10ml IV over 10 minutes

If seizures continue/recur: Monitor:

Stop Infusion: or if: or if: or if:

CONTROL HYPERTENSION

Antidote:

Treat hypertension if systolic BP 160 mmHg or diastolic BP 110 mmHg or MAP 125 mmHg Aim to reduce BP to around 130-140/90-100 mmHg Beware maternal hypotension and fetal heart rate abnormalities monitor FH with continuous CTG LABETALOL Up to 50mg IV stat slowly then erect IV infusion: 200 mg in 200 ml N Saline at 40 mg/hr, doubling dose at 1/2 hourly intervals as required to a maximum of 160 mg/hour NIFEDIPINE 10mg oral stat dose; repeat every 20 mins to a maximum of 40mg HYDRAZALINE 10mg IV slowly. Repeated doses of HYDRALAZINE 5mg IV 20 minutes apart may be given if necessary Close liaison with anaesthetists: may require plasma expansion There is no place for the continuation of pregnancy if eclampsia occurs STABILISE THE MOTHER BEFORE DELIVERY DELIVERY IS A TEAM EFFORT involving obstetricians, midwives, anaesthetists and paediatricians Ergometrine should not be used in severe eclampsia syntocinon 5 units im / slowly iv may be used Consider prophylaxis against Thromboembolism Maintain vigilance as the majority of eclamptic seizures occur after delivery

If not postpartum DELIVER

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APPENDIX 3
Abbreviations AFV ALT AST BP CPR CSU CTG CT CVP ECG EFW FBP FH HELLP HDU ICU IUGR IPPV IV LFTs MAP MEWS MgSO4 MSSU RCOG U&E Amniotic Fluid Volume Alanine transaminase Aspartate transaminase Blood pressure Cardio-pulmonary resuscitation Catheter sample of urine Cardiotocography Computer assisted tomography Central venous pressure Electrocardiograph Estimated Fetal Weight Full blood picture Fetal heart Haemolysis, elevated liver enzymes, low platelets High dependency unit Intensive care unit Intrauterine Growth Retardation Intermittent positive pressure ventilation Intravenous Liver function tests Mean arterial pressure Maternal Early Warning Score Magnesium sulphate Mid-stream sample of urine Royal College of Obstetricians and Gynaecologists Urea & Electrolytes

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APPENDIX 4
Emergency Box for Eclampsia
1. Drugs Magnesium sulphate 50%, 5 g in 10 ml ampoule Calcium gluconate 10%, 8.9 mg in 10 ml ampoule Hydralazine 20 mg in 1 ml ampoule Labetalol 200 mg in 20 ml ampoule Sodium chloride 10 ml ampoule 10% Calcium Gluconate 10 ml IV Intravenous fluids 250 ml bag of Sodium chloride 1 litre of Hartmann's solution IVAC giving set IV blood giving set Venous access 20G Cannula (pink) 18G Cannula (green) 16G Cannula (grey) Tourniquet Fixation tape Airway equipment Guedel airways: sizes 4, 3, and 2 Laedal bag, mask and valve Green oxygen tubing 2 meters Yankaeur sucker Other equipment 50 ml syringe 20 ml syringe 10 ml syringe Green needles Reflex hammer

x x x x x x

10 amps 2 amps 2 amps 1 amp 10 amps 10 amps

2.

x x x x

2 1 1 1

3.

x x x x x

2 2 2 1 1 roll

4.

5.

x x x x x

2 2 2 2 1 25

APPENDIX 5
Patient Information
Patient information packs can be obtained from: ACTION ON PRE-ECLAMPSIA (PEC) 105 High Street Evesham Worcs WR11 4EB Tel: 01386 761848 Email: info@apec.org.uk www.apec.org.uk Registered Charity Number: 1013557

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APPENDIX 6
Membership of the Pre-eclampsia and Eclampsia Working Group
Chair Dr H Sidhu Members Dr A Harper Dr D McAtamney Dr C McAllister Mrs K McDaid Miss N Porter In attendance Mrs C Le Guiniec Peer Review These guidelines have been peer reviewed as per NICE guidelines. Administrative Support GAIN Consultant Obstetrician Consultant Anaesthetist Consultant Anaesthetist Assistant Director of Healthcare Guideline & Audit Manager Belfast HSC Trust Belfast HSC Trust Southern HSC Trust Western HSC Trust GAIN Consultant Obstetrician Southern HSC Trust

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Further copies of this guideline can be obtained by either contacting the GAIN Office or by logging on to the website. GAIN Office DHSSPS Room C4.17 Castle Buildings Stormont BELFAST BT4 3SQ www.gain-ni.org ISBN Number: 978-1-906805-25-8